According to the findings of new research, the risk of newborns experiencing a medical mistake during treatment in the neonatal intensive care unit (NICU) is substantially higher for twins and triplets, when compared to infants who were a single birth.
Roughly one-in-seven sets of twins will suffer a wrong-patient error, and one-in-three sets of triplets will experience similar problems, according to findings published last week in the medical journal JAMA Pediatrics.
Researchers studied 1.5 million medical orders placed for nearly 11,000 infants in six neonatal intensive care units (NICUs) at two health care systems in New York City that used distinct temporary names for newborns.
Data was collected from four NICUs at New-York Presbyterian Hospital from January 2012 to December 2015 and two NICUs at Montefiore Health System from July 2013 to June 2015.
Researchers identified incorrect patient orders using an electronic system. They tracked orders that were placed and cancelled by a doctor within 10 minutes then reordered by the same doctor for a different patient within the next 10 minutes.
The risk of wrong patient orders was significantly higher among multiple birth infants compared to single birth infants. Multiple birth infants are infants born with two or more siblings, this includes triplets, quadruplets, quintuplets, and so on.
Wrong patient orders are orders for medication or medical procedures issued for one patient, but then given to the wrong patient. Often given to a sibling or another patient with the same or similar name. This can occur because the last name or full name is similar or in the case of twins and triplets, because the siblings look so much alike.
The increased risk of wrong patient error was mostly linked to identification errors occurring between siblings. Wrong patient errors occurred in 66 out of 100,000 medical orders among twins compared to 41 per 100,000 orders among single births.
Researchers noted that the risk was higher despite the Joint Commissions requirement for “distinct naming conventions.”
Strategies to reduce the risk of wrong patient errors such as using the given names for infants at birth and changing from temporary names like “Baby Smith” to given names when available should be encouraged. Similarly, doctors and hospitals can encourage parents to select names for multiple births before the infants are born to help prevent confusion.